Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation

Abstract

Background Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations. Methods We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material. Results There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation. Conclusions A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Efficacy of esophageal stents as a primary therapeutic option in spontaneous esophageal perforations: a systematic review and meta-analysis of observational studies

“…After the removal of duplicates, 541 records were identified and screened. Eventually, 18 studies [ 13 - 30 ] were included and are analyzed in this review, reporting on the use of stents as a primary treatment in cases of spontaneous esophageal perforations and their related outcomes in 171 patients. The study selection process is presented in Fig.…”

“…Overall, 64% (67/105) of patients were treated after at least 24 hours from the presumed time of esophageal rupture. Data on late presentation/treatment and related clinical outcomes were provided by 11 studies, including 75 patients in total [ 13 - 15 , 18 , 22 , 25 - 30 ]. The failure rate was 18% for late presenters (10/56) and 11% for early presenters (2/19).…”

“…On the other hand, our study did not suffer from inconsistency or significant publication bias, indicated by the measures of heterogeneity and Egger’s test of asymmetry, respectively. Moreover, the clinical success of the stent therapy was high, even though a significant number of patients presented late for treatment, were septic, severely debilitated and were therefore considered unfit for surgery [ 13 , 18 , 22 , 25 - 26 , 28 , 30 ].…”

Advances in minimal invasive treatment for esophageal perforation

“…Before discussing the combined approach presented by Chiu et al ( 1 ), I would like to remind all readers of the dangers associated with esophageal perforation and modern treatment options. Esophageal perforation is a true surgical emergency, occurring spontaneously as well as after various endoscopic procedures.…”

“…Endoscopic stenting has become common practice but is often complicated by stent migration, sometimes occurring repeatedly. Several techniques, including the novel alternative in the present work ( 1 ), have therefore been developed to reduce this problem. Finding a reliable method is important as stenting, in contrast to placing an end-cervical esophagostomy, results in esophageal preservation and superior long-term outcome ( 7 ).…”